Request for Services

Request for Services

Thank you for your interest in services at Reclaim Psychological Services! If you are seeking counseling or assessment services, please fill out the request below. This form takes approximately 1-2 minutes to complete. Do not use this form in case of emergency or if you or your child are feeling suicidal. Instead, please call 911, go to your nearest emergency room, or contact the National Suicide Hotline at 988.
Who is this appointment for?*

MeSomeone Else
Your Name*

First NameLast Name
Name of Prospective Client*

First NameLast Name
Date of Birth*

MonthDayYear
Prospective Client's Date of Birth*

MonthDayYear
Name of Guardian / Parent*
Parent/Guardian Phone Number*
Parent/Guardian Email*
example@example.com
Email*
example@example.com
Phone Number*

Referral Information
How did you hear about us?*

Primary Care PhysicianPediatricianFriendGooglePsychology TodayInsuranceMosaic CounselingOther
Name of Referral Source

Additional Information
Please feel free to use this space for any questions or concerns you would like answered before scheduling. Be sure to hit "Submit" below when you are finished. Thank you!
Please verify that you are human:*
Should be Empty:

Insurance